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Salter-Harris Epiphyseal Fractures


  • General Considerations
    • The epiphyseal plate (physis or growth plate) is the weakest part of the bone to shearing injuries
    • The Salter-Harris classification is a means of categorizing epiphyseal plate fractures and provides clues to their prognosis
    • All such these fractures, by definition, involve or extend through the epiphyseal plate so that all such fractures occur in children before the epiphyseal plate closes
  • Salter-Harris I Fractures
    • Occurs through the hypertrophic zone of the epiphyseal plate
    • Only the epiphyseal plate is fractured
    • Rarely produces complications
    • May be difficult to diagnose unless there is visible displacement of the epiphysis on the metaphysis
    • Slipped capital femoral epiphysis (SCFE) is an example of a Salter-Harris I fracture
  • Salter-Harris II Fractures
    • Most common Salter-Harris fracture -85%
    • Involves both the epiphyseal plate and the metaphysis
    • Small corner of metaphysis that is usually fractured produces the “corner sign”
    • Rarely produces complications
  • Salter-Harris III Fractures
    • Involves the epiphyseal plate and the epiphysis itself
    • Since the epiphysis is involved, damage to the articular cartilage can occur
    • Growth disturbance is uncommon
    • A Tillaux fracture of the ankle is a Salter-Harris III fracture
  • Salter-Harris IV Fractures
    • Involves the epiphyseal plate, metaphysis and epiphysis
    • Since it, too, involves the epiphysis, the articular cartilage can be damaged
    • Since these fractures involve the growing layer of cartilage, growth disturbance can result
  • Salter-Harris V Fractures
    • Rare
    • Compression or crushing injury of epiphyseal plate
    • Initial diagnosis may be difficult and not made until complication of growth disturbance at epiphyseal plate occurs resulting in angular deformities
    • Associated with growth disturbance
    • These injuries have the worst prognosis of the Salter-Harris fractures

 

Structures involved in Salter-Harris fractures

 

Type

Involves epiphyseal plate

Fracture of metaphysis

Fracture of epiphysis itself

I

Yes

 

 

II

Yes

Yes

 

III

Yes

 

Yes

IV

Yes

Yes

Yes

V

Yes

 

 

 

 

  • Clinical Findings
    • Point tenderness
    • Pain
    • Swelling
    • Limitation of motion
  • Imaging Findings
    • Soft tissue swelling
    • Depending on the type of fracture, some displacement of the epiphysis or corner sign (Thurston-Holland fragment)
    • Conventional radiography remains study of first choice
    • CT with multiplanar reconstruction has been used in problem cases
    • Ultrasound can be helpful in infants whose cartilage has not yet ossified
    • MRI in problem cases
  • Complications
    • Complications are rare
    • In general, the higher the number, the more likely the complication so that Salter-Harris types Iv and V have the highest associated complications
    • Greater risk for complication comes with fracture of distal tibia followed by distal femur
    • Primary complication is growth plate disturbance
      • Early closure
        • Limb length discrepancy
      • Closure of only a portion of the plate resulting in angular deformity

Salter 1 Fracture of the Proximal Humeral Epiphysis. Frontal radiograph of the shoulder in external rotation demonstrates slip of the proximal humeral epiphysis medially and inferiorly (black arrow) due to a fracture through the epiphyseal plate that causes widening of the plate (white arrow). The normal epiphyseal plate should not be confused for a fracture (see box).
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